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CITY OF CUPERTINO
BUILDING DIVISION PERMIT'��}��
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�Va ES17UDY AVE
TBD — TO BE DETERMINED
PERMrrNO
08060087
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SANITARY NO. CONTROL NO.
ARCHr ECr/ENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
70b Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DO) of Division 3 of the Businteas and Professioni Code, and my license is
ADD (682SQ) MASTERRBDRM, BTHRM, STUDY & ADJUST 3
in full force and effect
License Clan L.ic.r
EXISTING BEDROOM & ADD ENTRY
Dam ARCHI7ECT3 DECLARATION
PORCH (RMDL5 9 6 SQ) — SANITARY IS SVLE ' S
I undersland my plans shall be used as public records
licensed Professional
OWNER -BUILDER DECLARATION
I berehy affirm that 1 am uerript from the Contractors L.iecnse Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to cnitwuc4 alter, imprint, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed stalcmcnt
to the the contractor's ucetrse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant provisions of
section 70D0) Division 3 of de Business and Professlons Code) or
$ 6 5 0 0 0
(commencing with of
that he is exempt therefrom and the basis for the alleged exemption- Any violation of
3 7 5 0 8 0 4 9. E N Number
Occupancy p y T ype
O
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man ere hundred dollars (s M.
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the wort, and the srruclure is not intended or offered for sale (See. 7044, Business
and Profusion Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the ow ex -
builder will haw the burden of proving that he did not build or improve for purpose of
salc.).
I, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Cmdractoes Li-
ccnse Law does not apply to an owner of property who builds or improves themon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt der Sec B & P C for this reason
Owner Date
-
WORKER'S SATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of de Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insunrice, as required by Section
3700 of the Labor Code, for the performance of die wort for which this permit is Issued.
My Worker's Compesabort Insurance carrier and Policy number am:
Cartier. Polity No.:
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crltis section need not be completed If the permit is for one hundred dollars (S I00)
or less.)
,
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as m coo c obi to the Workers' Compensation
Laws of California. tc C
Applicant -
NOTICE TO APPLICANT. If, afar making this Ccrtifi c of Exemption, you should
become subject to the Workers Compcasdtion pmvisio of the Labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hem -by affirm that there is & construction lending agency for the performance of
' the work for which this permit is issued (Sec. 3097, Civ. C.)
Lcndees Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
'
' correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
.
(We) agree to saw, indemnify and keep harmless the Gty of Cupertino against
.
j liabilities, judgments, costs and expenses which may in any way accrue against said City
n conseq c g g of this permit
APPLI ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued : Date
SO CE U NS. n 0
�'— 2�
Re -roofs
Type of Roof
Signature of Applicant/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
codes ]yes 5532(a)7
Yes
❑�No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
W ll the applicant or future bu lding occupant use equipment or devices which
emit hayardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes 6No
I have road the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that If the building
does not curten0 have a tenant. that it a my responsibility to notify the occupant of thc
requirement7s rust be met prior to issuance of aCertificate ofOccup.nry.
Signature of Applicant Date
All roof coverings to be Class'}." or better
Dote
Owner or authonzrd agent